From the U.S. Government Accountability Office, www.gao.gov
Transcript for: Understanding and Estimating Pre-Existing Health
Conditions
Audio interview by GAO staff with John Dicken, Director, Health Care
Related GAO Work: GAO-12-439: Private Health Insurance: Estimates of
Individuals with Pre-Existing Conditions Range from 36 Million to 122
Million
Released: April 2012
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[ Narrator: ] Welcome to GAO's Watchdog Report, your source for news and
information from the U.S. Government Accountability Office. It's April
2012. Under current law, health insurers will be prohibited from denying
coverage, increasing premiums, or restricting benefits for adults with
pre-existing conditions beginning in 2014. A group led by John Dicken, a
director in GAO's Health Care team, recently reviewed some of the
effects of this provision. GAO's Jeremy Cluchey sat down with John to
learn more.
[ Jeremy Cluchey: ] The title of this report includes a major finding,
which is that the number of individuals in the United States with
pre-existing conditions is somewhere between 36 million and 122 million.
Why is this a challenging number to pin down exactly?
[ John Dicken: ] Well, it is challenging to get a precise estimate,
because each insurer can define the conditions that they will either
exclude coverage or charge higher premiums for on their own, and those
less for each insurer are considered proprietary, so it depends on which
conditions each insurer is choosing to either include or deny coverage
for.
[ Jeremy Cluchey: ] Can you talk about the five estimates you used to
reach this number?
[ John Dicken: ] Sure. The most conservative estimate, the lowest
estimate, was based just on eight conditions that are all very high-cost
conditions, including things like cancer or heart disease or diabetes,
so very high-cost conditions that any insurer that is allowed to deny
coverage likely would do so, so it's a very conservative estimate, and
that led to our 36 million lower-end estimate. Kind of in the middle, we
used estimates that were based on what high-risk pools would consider as
a pre-existing condition, and about 60 conditions that if an individual
would have those conditions they would be automatically considered
eligible for the high-risk pool. So that led to our mid-range estimates,
about 60 million adults with pre-existing conditions. And at the highest
end, we just included any chronic conditions, so some insurers may deny
coverage for those; others may not deny coverage for it. But if you
looked at all chronic conditions, about 122 million Americans with those
conditions.
[ Jeremy Cluchey: ] And you mentioned the different conditions
considered in each estimate. Can you talk about some of the most common
conditions that you identified in this category?
[ John Dicken: ] Sure. The most common, most prevalent condition among
adults was hypertension. There were over 30 million, 36 million adults
that have hypertension, and that was included in our widest estimate,
the largest estimate. The other most prevalent conditions include mental
health disorders and diabetes.
[ Jeremy Cluchey: ] Your team also looked at the demographics of those
with pre-existing conditions. Can you talk about the demographic profile
that you identified there?
[ John Dicken: ] Yeah. While pre-existing conditions certainly occur
across all different demographic and geographic groups, there were some
groups where were somewhat higher. Some of the pre-existing conditions
were more prevalent among women, for example. Not surprisingly, older
adults often had more pre-existing conditions than younger adults. We
did find that whites reported slightly higher prevalence of conditions
than other racial and ethnic groups, and then geographically there were
some variations. Georgia had somewhat lower prevalence of some
pre-existing conditions, whereas Kentucky had somewhat higher, but they
all were a few percentage points above or below the national average.
[ Jeremy Cluchey: ] How about income as a factor?
[ John Dicken: ] Yeah. Income, when we looked at income, there were not
strong notable relationships. I think even though pre-existing
conditions can result in individuals having to pay in some cases
thousands of dollars for the care of that condition, we saw that
pre-existing conditions were relatively comparable to the income makeup
in the population as a whole.
[ Jeremy Cluchey: ] For taxpayers and consumers of healthcare who are
interested in this provision and its potential effects, what's the
bottom line of this report?
[ John Dicken: ] Certainly for individuals who don't currently have
health insurance coverage, having a pre-existing condition can make that
very challenging. It really depends on kind of when individuals existing
health insurance coverage is and the laws of the state where they live.
So individuals who currently have employer-sponsored health insurance
are guaranteed protections, they can't be denied because of pre-existing
conditions, but that could change if they should lose their job or
otherwise lose their health insurance. So what exists currently, the
Patient Protection and Affordable Care Act, the health care reform law,
makes some important changes to all of this. Beginning in 2014, if the
law is fully implemented, then there will be more guarantees so that
individuals could not be denied coverage because of pre-existing
conditions, and they could not be rated based on their health status.
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